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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4416_Библиотеки_им_академика_М_И_Перельмана
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367Chapter 26 Approach to Nasal Obstruction
A
C
B
D
E
Figs. 26.2A to F: Nasoethmoidal masses of bony origin. (A) Chondrosarcoma. Extensive
chondroid matrix mineralization (asterisk); (B) Chondroid matrix mineralization (ring and
arc-shaped); (C) T2W hyperintense signal of the mass (asterisk) and retained secretion in
frontal sinus (arrow); (D) Lobular contrast enhancement of septae (arrow); (E) Chordoma.
Midline expansile lytic lesion with bone destruction (arrow); and (F) No contrast enhancement
of the mass (asterisk).
F
Section 7 Clinico-Radiological Approach368
A
C
B
D
E
Figs. 26.3A to F: Nasoethmoidal masses with bony sclerosis. (A) Olfactory groove menin-
gioma. Superior nasal cavity mass (asterisk) with intense enhancement on contrast-enhanced
computed tomography (CECT); (B and C) Hyperostosis of the frontal bone (arrows); (D)
Bonyexpansionofthenasalcavity(blockarrow);(E)Ossifyingbroma.Expansilebonymass
arising from right anterior ethmoid air cells (asterisk); and (F) Ground-glass matrix (asterisk).
F
Table 26.3: Nasoethmoidal masses and their
key imaging points (see Figs. 26.1 to 26.3).
Masses Key imaging points
Esthesioneuroblastoma • Soft tissue mass at superior nasal cavity with cribriform
plate erosion
• T2-weighted magnetic resonance imaging: Heterogeneously
hyperintense
• Intense contrast enhancement on CT/MRI
• T2WI bright areas (cyst) at the apical part of the tumor
(tumor/brain interface)
Chondrosarcoma • Soft tissue mass with bone destruction
• Matrixshowsringandarc-shapedcalcication
• Soft tissue mass with T2WI bright signal, lobular contrast
enhancement
Chordoma • Rare tumor, usually involves the spheno-occipital syncho-
ndrosis
• Expansile lytic bone lesion
• Lobularsofttissuemasswithfociofcalcication
• Heterogeneous T2W hyperintense signal
• Heterogeneous contrast enhancement
Meningioma • Unusual tumors
• Variable T2W signal on MRI (T2W hypointense)
• Intense contrast enhancement
• Bony hyperostosis
Schwannoma • Heterogeneous hyperintense T2W signal intensity
• Variable contrast enhancement
• Bony remodeling, lack of frank bone destruction
(CT: Computed tomography; MRI: Magnetic resonance imaging; T2WI: T2-weighted image).
369Chapter 26 Approach to Nasal Obstruction
Pediatric nasoethmoidal masses are covered in Chapters 20 and 23. Adult
nasoethmoidal masses are described in Table 26.3.
Congenital lesions are described in Chapter 20.
Nasal Cavity/Lateral Wall Lesion (Figs. 26.4 to 26.6)
Nasal cavity/lateral wall lesions are listed in Table 26.4.
Causes of masses arising from lateral wall of the nasal cavity are diverse
including mostly infective/ neoplastic lesions ( Table 26.4).
Several of these tumors are benign and dicult to dierentiate from common
inammatory pathologies such as polyps.
Section 7 Clinico-Radiological Approach370
A
C
B
D
E
Figs. 26.4A to F: Nasal cavity lesions causing obstruction. (A) Chronic rhinosinusitis
withpolyposis.Softtissueopacicationofrightnasalcavity.Enhancingmucosa(arrow);(B)
Widened and blocked OMC (asterisk); (C and D) Atrophic rhinitis. Mucoperiosteal thickening of
nasal cavity and maxillary sinuses. Destruction of turbinates (arrows), missing middle
turbinates(asterisks);(E)Rhinolith.Chronicrhinosinusitiswithmucosalthickeningandcalcied
areaswithin (block arrows)suggestiveofrhinoliths;and (F) Ossifying bromaofthenasal
cavitycausingnasalobstruction.Peripheralossicationofthemass(asterisk),withcentralhypo-
dense area.
F
371Chapter 26 Approach to Nasal Obstruction
A
C
B
D
E
Figs. 26.5A to F: Nasal cavity lesions causing obstruction. (A) Inverted papilloma. Expansile
mass lesion (m) involving right maxillary sinus and right nasal cavity; (B) Widening of maxillary
ostium(arrow);(C)Neurobroma. Large expansile soft tissue density mass(asterisk),left
maxillarysinus, nasal cavity,and sphenoid sinus; (D) Widening of pterygomaxillaryssure
and extension into pterygopalatine fossa and infratemporal fossa (arrow); (E and F) Ossifying
broma.Largeexpansilemixeddensitymasses in bilateral frontal and ethmoidal cells with
mass effect over the globes bilaterally; and nodular sclerotic component (arrow in E).
F
Section 7 Clinico-Radiological Approach372
A
C
B
D
E
Figs. 26.6A to F: Nasal cavity masses causing obstruction. (A to D) Juvenile
nasopharyngeal angiobroma. Intensely enhancing heterogeneous mass lesion centered
near right spheno palatine foramen extending into, bilateral ethmoids, posterior choana, and
nasopharynx (asterisk). Laterally extension into the pterygomaxillary ssure (arrowhead
in A). Intermediate signal intensity with prominent ow voids on T2WI (arrow in B). Intense
postcontrast enhance ment (asterisk in C). Erosion of pterygoid base and widening of inferior
orbitalssure(arrowinD).(EandF)Nasopharyngeal carcinoma. Large enhancing mass
in nasopharynx, involving posterior wall of nasopharynx (asterisk in E). Note: Retained
secretion in sinuses (arrow). Destruction of frontal bone (arrows in F).
F
Table 26.4: Clinical and imaging ndings of nasal
cavity/lateral nasal wall lesions causing obstruction.
Disease Salient clinical/imaging ndings
Rhinosinusitis (Figs. 26.4A to F) Discussed in Chapter 4
Rhinolith (Figs. 26.4A to F) • Rare, calcareous concretions which form in the
nose due to deposition of salts around a foreign
body
• Result in foul smell and discharge
• Exogenous foreign bodies usually located near
theoor;maybeendogenous(bloodclots/tooth
fragments)
• Localinammatoryreactionleadstodeposition
of calcium, iron, magnesium salts, and organic
substances
• CT displays size and site of the rhinolith
preoperatively.Appearsasawell-dened,dense,
and nearly osseous lesion within the nasal cavity.
Mostly, no associated soft tissue lesion seen.
Inverted papilloma
(Figs. 26.5A to F)
Juvenile nasopharyngeal
angiobromas(JNAs)
Nasopharyngeal carcinoma • Mass in posterior nasopharyngeal wall
Rhinoscleroma Middle and inferior turbinate earliest site
Rhinosporidiosis Inferiorturbinate,inferiormeatus,oor;spreadtoNLD
(CT: Computed tomography; MRI: Magnetic resonance imaging; NLD: Nasolacrimal duct).
Numerous staging system used, Krause’s system
being most commonly followed
• Stage 1:Connedtonasalcavity
• Stage 2: Ethmoid sinuses, maxillary sinus (medial
and superior region involved)
• Stage 3:Allparanasalsinusesbutconnedto
nose/sinuses
• Stage 4:Notconnedtosinuses/malignant
• Mass with center in sphenopalatine foramen
• Extension into the pterygopalatine fossa and
bowing of posterior maxillary wall
• Intense enhancement after contrast administration
on CT/MRI
• Older age, short duration of symptoms
• Soft tissue mass with bone destruction
• Nocalcication
and lacrimal sac
373Chapter 26 Approach to Nasal Obstruction
Section 7 Clinico-Radiological Approach374
Nasal Septal Lesions (Figs. 26.7 and 26.8)
e list of nasal septal lesions is exhaustive (Table 26.5), and imaging is
indicated in the lesions associated with soft tissue. e diagnostic algorithm
towards erosive nasal lesions is described in Flowchart 26.1. Most of the
entities have been covered elsewhere in the book.
Table 26.5: Nasal septal lesions (Figs. 26.7 and 26.8).
Causes Key imaging points
Congenital
Acquired Traumatic • Surgical
• Iatrogenic
• Self-inicted
Infective • Fungal
• Tuberculosis
• Syphilis
• Leprosy
• Rhinoscleroma
• Actinomycosis
Toxic • Cocaine use
• Other inhalants
(chromium
salts)
• Nasal steroids
Inammatory • Granulomatosis
with polyangiitis
(GPA)
• Sarcoidosis
• LSS
Tumors • Midline lethal
granuloma (now
recognized as a
form of NHL)
• Metastasis
• Melanoma
• No associated mass
• More frequently iatrogenic
• Occasionallyself-inicted
(rhinotillexomania) consequent
to chronic nose picking, e.g. in
severe obsessive-compulsive
disorders
• Anterior and inferior part of septum
involved rst
Collection of pus between the nasal
septum and the mucoperiosteum or
mucoperichondrium, depending on
the part of the septum involved.
• Following trauma or in
immunosuppressed individuals
• Adjoining sinusitis
• Dental infection
• Infection in underlying dermoid
cyst
• Midline lesion
• May be associated with mass
375Chapter 26 Approach to Nasal Obstruction
A
B
C
Figs. 26.7A to D: Nasal septal perforation without mass lesions (mucosal thickening
may be present). (A) Septal perforation after fungal rhinosinusitis. Mucoperiosteal thickening
of the turbinates and right maxillary sinus. Large septal perforation (arrows) at the bony
part; (B) Nasal septal perforation in granulomatosis with polyangiitis (GPA). Left maxillary
sinusitis. Perforation of the inferior nasal septum (arrow) but hard palate (hp) spared; and (C
and D) Nasal septal perforation after functional endoscopic sinus surgery (FESS). Residual
mucosal thickening in nasal cavity, ethmoid, and maxillary sinuses. Bony septal perforation
at the inferior part (arrows).
D
Section 7 Clinico-Radiological Approach376
A
C
B
D
E
Figs. 26.8A to F: Nasal septal destruction associated with mass lesions. (A) Septal
destruction in sinonasal PNET. Homogeneously enhancing mass lesion in the nasal cavity
and ethmoids (m); (B) Destruction of the nasal septum (arrow) at the bony part; (C and
D) Nasal septal destruction in esthesioneuroblastoma. Large mass (m) with epicenter at
superior nasal cavity. Isointense signal on T2WI. Nasal septal destruction (arrows); and (E
and F) Septal erosion in NK/T-cell lymphoma. Homogeneous mass (m) with erosion of bony
nasal septum erosion (arrow).
(NK: Natural killer; PNET: Primitive neuroectodermal tumor; T2WI: T2-weighted image).
F
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